Deficiency Records for Alexandria Rehabilitation and Healthcare Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Alexandria Rehabilitation and Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-07-12 | 2022-08-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-07-12 | 2022-08-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-07-12 | 2022-08-30 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2022-07-12 | 2022-08-30 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-06-29 | 2022-08-24 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-06-29 | 2022-08-03 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-06-29 | 2022-08-03 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-06-29 | 2022-08-03 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-29 | 2022-08-03 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-06-29 | 2022-08-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-06-29 | 2022-08-03 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-06-29 | 2022-08-03 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-06-29 | 2022-08-03 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-06-29 | 2022-08-03 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-06-29 | 2022-08-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-29 | 2022-08-03 | N |
| Dispose of garbage and refuse properly. | Health | 2022-06-29 | 2022-08-03 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2022-06-29 | 2022-08-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-29 | 2022-08-03 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-06-29 | 2022-08-03 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2022-06-29 | 2022-08-03 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-01-30 | 2020-03-09 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-01-30 | 2020-03-09 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-01-30 | 2020-03-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-30 | 2020-03-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-30 | 2020-03-09 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2020-01-30 | 2020-03-09 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-01-30 | 2020-03-09 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-01-30 | 2020-03-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-30 | 2020-03-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-01-30 | 2020-03-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-30 | 2020-03-09 | N |
| Use approved construction type or materials. | Fire Safety | 2019-03-14 | 2019-05-23 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-03-14 | 2019-05-23 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-03-14 | 2019-05-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-03-14 | 2019-05-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-14 | 2019-05-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-03-14 | 2019-05-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-03-14 | 2019-05-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-03-14 | 2019-05-23 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-03-14 | 2019-05-23 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-03-14 | 2019-05-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-03-14 | 2019-05-23 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2019-01-25 | 2019-03-05 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-01-25 | 2019-03-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-25 | 2019-03-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-01-25 | 2019-03-05 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-01-25 | 2019-03-05 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-01-25 | 2019-03-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-01-25 | 2019-03-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-01-25 | 2019-03-05 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-01-25 | 2019-03-05 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-01-25 | 2019-03-05 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-01-25 | 2019-03-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-01-25 | 2019-03-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-30 | 2019-02-17 | N |
